1154321602 NPI number — BENEVOLENT CORPORATION CEDAR COMMUNITY

Table of content: (NPI 1154321602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154321602 NPI number — BENEVOLENT CORPORATION CEDAR COMMUNITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENEVOLENT CORPORATION CEDAR COMMUNITY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CEDAR LAKE CAMPUS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154321602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5595 COUNTY ROAD Z
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BEND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53095-9224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-306-2140
Provider Business Mailing Address Fax Number:
262-306-2141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5595 COUNTY ROAD Z
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BEND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53095-9224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-306-2140
Provider Business Practice Location Address Fax Number:
262-306-2141
Provider Enumeration Date:
07/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PICHLER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
T
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
262-306-4212

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  5115503 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X , with the licence number: 5115503 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33027100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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